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HomeMy WebLinkAboutT15N R2W SEC 25 LT 26 E2 ' ~ ' MUNICIPALITY OF ANCHORAGE e DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ..... PHONE [] NEW LOCATION NO, OF BEDROOMB DISTANCE TO: [ ~3LC9 I Li~. ~c paciW in gallons IF HOME.DE: ns de ~nflth Width Liquid dopth ~ ~ DISTANCE TO: Well ~welling PERMIT NO. ~ _ ~ ] ~ Material Liquid capacity in gallons J DISTANCE* TO: Well / ~ / Foundation~ t ~ Nearest~lo~in~ ,~ PERMI~ ~ ~ No. of lines Z Leng~ ~7~' Total a leng~ li~es Trench wi Distance between Total effective absor ion area ~ ~ Top of tile to finish grade /O, Mateda]benoathtilo ¢0 inches Length Width Depth PERMIT NO. ( ~ Type of crib Crib diameter //Crib depth Total effective absorption area m Well uild[ng foundation Nearest lot line ~ DISTANCE TO: ~ Si a s~ /~%/~ jO~th~ Driller Distance to lot line PERMIT NO, m Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER REMARKS --~ ¥ DATE L AL "'~ .... PH, 694~X979 ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION SOILS LOG -- PERCOLATION TEST [] SOILS LOG PERCOLATION TEST LEGAL DESCRIPTION: 2 3 7 SLOPE SITE PLAN 10 11 12 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ (minutes/inch). TEST RUN BETWEEN '~ FT AND '~ FT 13 14 15 COMMENTS No, 1457-E 72-008 [6/79) ":' :[ ~,,,3'J. ]. ]. ir~srLa]. ]. tlh~e ::,y =, L,:ln: ~;ri ac:,'.::c!r'd.arm:(~.!! :/~.~. l.~: i"tC]~:~ c::cli:;h.~!_~i and lrF' ;'~ .......] STF~'IF!Oiq ]:'~ ]Z,iSIT'F~L.L_EZ) ~.l,~ ;~,:..:,l:.~::.:: F~':)F'::IF:'B BY I"iOFN :'::~ "[ i~'t'I~,IC: ~''I~llV:'I':>:~:I; Ll!::l:'l, , ?: : ~):' l~ '-- --': .......... :::LI':':'~ l t='':'~''::L'' :--,[X,:.= ~Z) TI''IF:' ~''I':'L''L' NOT d'!--! :~['V~ LJ I~i]:'I--H[]LIT ~'[xl ""' '~'''""''*r .... :[iNIEi!:::'IECTT']:f]Iq :::':='~:'r~l::Fr,, ;N :V', IE!.:..IECT!R :i: Chgl__ {({:]l:il'::: MI,.IE}'T BE )Z]NE ii:',Yi~:~ L I CZ]qE}IEB iELEC}TR :[ C :[ F.~ff',l ,: '"'" ,, ~, [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST LEGAL DESCRIPTION: -- 4'u 1 2 3 7 8 SLOPE SITE PLAN ! / / , 10 11 13 14 15 16 17 18 19 2O COMMENTS PERFORMED BY: 72-008 (6/79) WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~'~} (minutes/inch) TEST RUN BETWEEN ~'" FT AND ~g~ FT --' ~o-~ow~ off P~b~ ~ber'l A. 5ho~t No, 1 a~S7'E Rick Mystrom, Mayor Mumcipality of Anch°rage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 October 11,1994 Louis A. Butera, P.E. Eagle River Engineering Services P.O. Box 773294 Eagle River, Alaska 99577 Subject: Waiver Request for: East ½ of Lot 26, T~:~, R2W, Sec 25 Waiver Approval: # WR940055 Dear Mr. Butera, Your application for waiver(s) from the required separation distances is approved as follows: Well to Tank Well to leachfield 97 feet 96 feet This waiver approval applies to the existing septic system only. Any future upgrades will require all separation distances be met or another approval be obtained from this department. j~m~rely' /~ Program Manager On-site Services. Ijm: #6 ~ MUNICIPALITY 'OF ANCHORAC~ Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR9 WR940055 PID# 051-281-62 Date Received: 10-11-94 HA# HA940534 Permit Legal Description: East ~ of Lot 26. T15N~ ~2W~ S~ 25 Engineer: Louis A. Butera, P.E. Eagle River Engineering Services P.O. Box 773294, Eaale Riverr Alaska 99577 Applicant: Secretary of HUD Waiver Requested: Multiple, Well to ~] [~ ~w~ Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient ~,~ E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: Y Waive List Conditions or Reasons for above: _~ Date: '0 [~.~ J~ By: ~ ~ ' N Rec ~: 00387 Amount: $ 920.00 "~ ~ ~ .'~. ~P~-~' /~. .' o ~.a~? ' ~ ~ ' ..'°."~ ~' . ~ ~.~ ,~, . , .. ..~ ,.. ~ ASBUILT-NO CORNERS SET THIS ATE. "' ' 8 D'~:ASSOCTA?~ ~ 8~IN~'69~0~2 · I HEREBY CERTIFY .THAT I HAVE SURVEYED' THE SCALE, FOLLOWIN6 DESCRIBED PROPERTY~ ~'~-~'~-"~"~'~'~x'r"~' ~ ~~ . DATE, AND ~AT NO EN~OACHMENTS EXIST ~CE~ AS " INDICA~D, IT IS THE RES~NSIBILITY OF THE OWN~ TO D~ERMINE THE EXISTENCE OF ANY GRID~ E~EMENTS~ COVENANTS~ OR RESTRICTIONS WHICH DO NOT ~PEAE ON THE RE~D~ VISION PLAT. UNDER NO CIRCUMSTANCES S~ FB~ ~Y DATA H~EON BE USED FOR 'CONSTRUCTION OF FENCE LINES, OR FOR EST~LISHIN6 ARY LINES. DRAWN~ r Pot,~ rs = Ig,°r Water sample results for coliform and Nitrate are attached. The samples indicate zero colonies of bacteria, and a Nitrate level of 2.8 mg/L. The names and addresses of the adjacent land owners are as follows: Wl/2 Lot 26, T15N R2W Section 25 William Hahn HC 78 Box 3240, Chugiak, AK 99567 Lot 27, T15N R2W Section 25 Paul & Mary Ellen Erickson P.O. Box 771744, Eagle River, AK 99577 Rosha, Lot 10B Robert & Susan Shaw SR1 Box 3140, Chugiak, AK 99567 Splawn, Lots lib & llC Bradley & Melanie Gerkin 17922 Hill Crest Drive, Eagle River, AK 99577 Statement of positive and negative impacts: * The waiver will rectify an existing violation of a system which is performing adequately. * Negative impacts are negligible. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. Attachments: Asbuilt survey Location map Well logs Soils logs Water samples \C:\WPWIN60\WPDO CS\1994\94-067A.NAR 2 Louis Butera, P.E. Registered Civil Engineer October 10, 1994 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: El/2 Lot 26, T15N R2W Section 25 17927 Kamkoff Avenue, Chugiak Waiver Application Dear Mr. Cross: On behalf of our client, we are requesting a three foot waiver of the required 100' horizontal separation distance from the on-site septic tank to the on-site private well, serving the property referenced above. Additionally, we request a four foot waiver of the 100' horizontal separation distance from the leachfield to the on-site well. The well and septic system have been in use since 1985. The well and septic systems had acceptable performance during a recent adequacy test conducted by ERES, and we feel the expense of an upgrade is not warranted for a four foot infraction. Surface drainage is generally from the well towards the tank and field, supporting our waiver. Grade slopes approximately 5% to the southeast at the tank and field locations, also supporting our waiver. Attached are well logs for Lots 25 & 24 T15N R2W Section 25; Lot 3 Ford Subd.; Lots 2 & 5 Benson Subd.; Lot 58B Gilbert Subd.; and Lots 1 & 2 Robanna Subd.. Depths range from 60'-260', with static levels from 24'-120'. The logs indicate several thick protective layers of silty gravel, clayey gravel and hardpan. Some wells appear to draw from bedrock at substantial depths. No well log was available for the El/2 Lot 26. An earlier inspection report indicates the well was probed to 97' total depth, and our test showed a static level of 67' with a total drawdown to 71' during testing. Attached are near surface soil logs for El/2 Lot 26, 34, 35, and 51, TI5N R2W Section 25; Lot 1 Robanna Subd.; LOt 3 Ford Subd.. The logs indicate 13' of GM for LOt 26 with surrounding areas having GW/GP, clayey gravel, clay, silty sand, and silt layers. \C:\WPWIN60\WPDOCS\1994\94-067A.NAR P.O. Box 773294 · Eagle River, Alaska 99577 · Telephone (907} 694-5195" Fax (907} 694-3297 2.5' 24 49 6O KAMKOFF AVF-- 79 8O 82 115 18027 )6240 //6 ~ 8 62. ..~(~ 63 66 Eagle RiverlChuglak Area Reference Map--lC ...4 : , -. · , , ?~DOR~: ' ' :'" STATIC LEVEL OF WATER ~. , ,,.,.', ,, . ~A~.PEr HR ,..... :, ;. ~,~uo,~ ~ . ....... . ',. ~.:- ,~:.'~ ~PL ~,''~ Ft. z~.,.(O~ '~r~u-'"'-'~' ~ ~ ' ELtO ' ~t.. ~...;, ~ , ........... n~ ' -.'.. · ~ r~ m ',. F~: ' ' ~,[.. ,-. , .. . , . .... ~ ' Ft., F~m__ - ' ' ~,;; FL F~ SULLIVAN WATER WELLS. .:. P.O. BOX272~CHUGIAK. ALASKA~gE~7 ~ TELEPHO~, E688'2759. · . . ,. .. . '..' .- .~ . · . '.. .: ·., - _,,~ ..... . .- ..~ ,'~... KIND OF FORMAT[ON: From O FCt~ / From Ft. o / From~'/ FLto Fro~ ~7~ FL ~o From ~'<~' Ft. to From <~ .O Ft. to From ~? :~ Ft. to '=~ ~" From ~ Ft. to ./ From ./.3 ! Ft. to / From / ,-;f Ft. to / From Ft. to From /'~:~ Ft. to/~ Ft F~;om Ft. to-do=Ft. From Ft. to Ft. From__ Ft. to Ft. From__ Ft. to Ft. From__ Ft. to Ft. Ft ~",~.,~,~ ?' ~'~'~T~ From .. FL ~1 ~ From . . F~ From.~ . FL ~ . ~ , .~ ~ ~ From From From From From From From From Ft. to Ft. Ft. to Ft. ,Ft. to Ft.__. Ft. to.~Ft, Ft. to Ft Ft.to Ft. Ft. to Ft. Ft. to Ft. .Ft. to Ft._ Ft. to Ft._ Ft. to Ft. Ft. to Ft. FL to Ft. Ft. to ,Ft._ __Ft. to Ft. Ft. to ,Ft.__ Ft. to Ft MISCL. INFORMATION: DRILLER'S NAME :- "" " '-"! .... MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~ SOILS LOG [] PERCOLATION TEST DATE PERFORMED: _~'¢~ -25' 1 2 3- 4- 5- 6- 7- 8- 9- 10- 11 13- 14 15- 16- 17- 18. 19.- 20- COMMENTS SLOPE SITE PLAN WASGROUNDWATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch} TEST RUN BETWEEN , FT AND , FT PERFORMED Ry: CERTIFIED BY: ~'~"~"<~-~--' DATE'. 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99E01 2644720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMED FOR: ~T~ (~A~.¢c~ LEGAL DESCRIPTION: /~o7c --~'-/ T~}~- N /~ / '~] -~ DATE PERFORMED: SLOPE SITE PLAN 1 2 3 4 5 7 8 9 10 ND WATER 11 TERED? FWHAT 13 - Reading PERCOLA] Gross Net Depth to Net Reading Date Time Time Water Drop ~ ,, i; ~ /~'~,~ g '-~% '~" 14- 15- 16- 17- 18- 19- 20- TION RATE / ~ 3 ~/'//3/~ /~ (minutes/inch) TEST RUN BE'I1NEEN ~' FT AND 7 FT COMMENTS PERFORMED BY: Eagle River Engineering Services Eagle River, AK 99577 6944195 CERTIFIED BY: J~ PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 (- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 Lo Street, Anchorage, Alaska 99501 264~720 SOILS LOG - PERCOLATION TEST SOILS LOG [] PERCOLATION TEST 10 11 WAS GROUND WATER ENCOUNTERED? 12 13- IF YES, AT WHAT DEPTH? 15 16 17 18 19 2O COMMENTS Gross Net Depth to Net Reading Date Time Time Water Drop MUNICIPALITY OF ANCHORAGE OEPAfl' NT OF HEALTH AND ENVIRONMENTAL p~ ,'ECrION [~ PERCOLATION SOILS LOG - PERCOLATION TEST 12 14- ~15 16 17- G,-m~ N~ D~h ~o N~ Time Time Wet~, ~ /', , .~ ,.,~.~.. __ / . TE~ RUN BE~EEN FT AND . FT : :' ' ~' ~ CERTIFIED O & E ENc '" tE.E__RING & D'EVELO '"~IENT CO./ .,, " ...... ,,-~' ' BOX ~ Deal,-St., Eagle Rl~e~, Alaska 9~7'/' :'" ' ' ' ~ "~ o~pth (f~) 0 1 2 3 4 5~ 6~ 7~ 8~ 9~ 10 11 12 .13 __ 14 PLOT PLAN PERC. TEST Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: Date,' Performed by: Parcel I.D. # MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERALINFORMATION Complete legaldescription El/2 Lot 26 T15N R2W Section 25 Location (site address or directions) 17927 Kamkoff, Chugiak Property owner Mailing address Lending agency Mailing address Agent Address 222 W. 8th Av~.. Anchoraqe. AK N/A Day phone. 258-8888 qqs13 Day phone Sandy Hjelmsted/rAssociated Brokers Day phone 258-8888 2509 Eide Street, Suite 4, Anchorage, AK 99503-2634 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: 72-025(Rev. 1/91) Fronl ,MOAR21 X If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. , . . = u':.;':" ~.. If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of System. ' .... 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my inves_tLgation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with ali Municipal and State codes, ordinances, ~nd regulations in effect on the date of this inspection. '>...:; , Name of Firm Eagle River Engineering Services Phone 694-5195 Address P.o. Box 773294, Eaqle River, AK 99577 Engineer's signature Date /'~ - / / - ? Y DHHS SIGNATURE /'/~Approved for '~' Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: _ _ Date The Mumclpahty of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificat,e,s~, based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The D H HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the profe~!onal engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) ,,V~ Parcel I.D. O5/ - ~/- ~'~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~1[)~ 7'O /~)~(2 Driller Casing height Cased to Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG / / SEPARATION DISTANCES FROM WELL TO: Septic/heldiRg tank on lot ~ ~ ~' Absorption field on lot ~/'~ ~ Y" Public sewer main ~/P) Sewer service line AT INSPECTION ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform "~- Date of sample: ~ ~/~- '~ ./? ~ Nitrate ~., ~'~_ /'~//L_ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) ~'~ High water alarm (Y/N) Date of pumping Tank size / Z 5 ~ Compartments Foundation cleanout (Y/N) .N~ Depression (Y/N) /t///~ Alarm tested (Y/N) /,//,~z ~/~,/q/-/ Pumper '--J/~ $ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~2 '~ To property line /¢ 0 Surface water/drainage Foundation ~' Water maiWservice line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons_ Vent (Y/N) High water alarm level _ ..----'~'~ Cycles tested Meets MOA electrical codes (Y/N~).) ~ SEPARATION D~I,~T-AN~E FROM LIFT STATION TO: Well on lot On adjacent lots Manufacturer Manh o1~/)1~'""'~ "Pump on" level at ~ "Pump off" Level at Surface water D. ABSORPTION FIELD DATA Date installed 0'~/~ ~ Soil rating (GPD/Ft2) ,~'~ '~' .///3~ Length_ ~ ~ Width ...~O /~ Gravel thickness z~ / Total absorption area ~)0(~ ~ Cleanout present (Y/N) Date of adequacy test r~ ¢/¢'¢//¢~ Results (pass/fail) Water level in absorption field before test /;~// Peroxide treatment (past 12 months) (Y/N) System type Total depth y~ Depression over field (Y/N) /2~ $ ~ for After test /, If yes, give date /"/// Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ¢~ To building foundation On adjacent lots % Surface water Curtain drain On adjacent lots 'f/00 / Property line ~ *¢ / To existing or abandoned system on lot Cutbank /'//~/ Water ~[~ai~/service line Driveway, parking/vehicle storage area /~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect Signature Engineer's Name CE-6736 HAA Fee $ Date of Payment Receipt Number 72-026 (8/93)' Back Waiver Fee $ Date of Payment Receipt Number 0~: ~'7 CT&E E~JIRO~MENTR- LRB SERUICES -~ 9~? G94 329? NO. 6~4 Commercial Testing & Engineering Co. Environmental Laboratory Services ~ LABORATORY ANALYSIS REPORT Cli,mt Sampl~ ID E 1/~ J .OT 26 TI 5'N"P.~W I~tt~ix WATER ~633 B Street, Anchorage, AK 99518-11500 -- Tek {907) 582-2343 Fax: (9071 561-6301 iEf,.flJtRON ME~t'AL FACILI'F~ E~ IN AIJ~,~F~'~-, COLORADO, FL-ORt'~, tLUNO~$. MARYLAND, NEW* JERSEY. OHIO, UTAH, WE~'T VIRGINIA MUI"~IC[PALI i Y ©P Aix~C~©RAGE DgPAtTl'i"3~!N.r (%: H~:ALTH At'ID ENVIRONMENPAL i~RO'I'gCTION L}!ViSJON OF E,NVIf~ONMEN'FAL HEALTH CEJ:~ Ih" tE;A"i E OF INSPEC-'i ION FOR HEALTH AUTHORITY APPROVAL OF ON-SPi E SEWER AND WATER FACILITY 264-4720 Application Date Leg;al Description (include Iol, block, subdivision, section, township, range) Locagon (a. dd~ess or directions) 1700 Link Court (b) Applicant Name Gre¢_ Har.Oztan Telephone: Home ~,~_5~_---,.~r~_~___ Business App!icantAdd~ess 1700 Linen C0u&~.~,~A_rL¢~.¢z~,~&~a. 9_°zZfL4_ (c) Applicant is (check one): Lending Institution []; Owner/buildel'~; Buyer ~-; Other [] (explain); (d) t_ending Institution Na~_ First Mozk-f. gcgg__ Telephone 563-5~LLI (e) Real Estate Company and Agent Coldwell. Banke.r~/Sh~/mn Add~ess ___E~g~.6_~V~L~A~&~ 99577 M~t~t ~e HAA to the following address: ~RB_i~6X _Eccgl~iv_e&~la,3 ka 995 ZZ TYPE OF RESIDENCE Single-Family ~ Multi-Family [] Number of Bedrooms 4 Other WATER SUPPLY Individual Well [] Corpmunity [] Public [] Note: If corn mLmity well system, must have written confirmation from the State Department of Environmental Conservation attesting to tire legality and status. SEWAGE DISPOSAL Onsite [] Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status. Page t of 2 72-025(11~84) ,",¢; ce~ dfird by my seal affixed hereto and as of the validation date shown below, I verify ll]ai my investigation of this Health At,iho~ ily Apl.,r ov~tl sinews that the on-site water supply and/or wastewater disposal system is safe, functional and adeqoate i(i die i~umber of bedrooms and type el structure indicaled herein. I luther verify that based on the information obtained bom ff:e M(micipaliiy el Anchorage files and from my investigation and inspection, the on-site water supply and/or w;;sh:w:l(er disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on DHEP APPROVAL Approved Ior ?~ .~'~_____ bedrooms by Approved __~,4, _ Disapproved 1 chris of Conditioeal Approval Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority App~owd certificates based solely upon the representations given in paragraph 5 abov6 by an independent professional engineer registered in the Stele of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the prolessional engineer's work. Page 2 of 2 12-025 (11/84} WELL DATA Well Classification Well Log Present (Y~ Total Depth ¢/,2. / Static Water Level Casing Height Above Ground Electrical Wiring in Conduit Y~NI' Separation Distances from Well: To Septic/Holding Tank 6n 'Lot To Nearest Edge o! Absorption Field on Lot TO Nearest Public Sewer Line ~'/~' Clean6ut/Manhole ~ Water Sample Collected by ANCHI~?AI~I~CIPALITY OF ANCHORAGE (MOA) MUNtCtP^UTY OF DEPT. Of HEALTH I~EALTH AUTHORITY APPROVAL (HAA) ENVirONMENTAL P~O~ECTIO~HECKLIST ' FEBRUARY 1984 264-4720 ~ gg~ Legal Description: ZOrZ~ Cased to /'7/~ / ~' ,.~-/ / If A, B, C, D.E.C. Approved (Y/N) Date Completed ~. '~-4~ //~'~7o Yield Depth of Grouting Pump Set At ¢'/'/¢ Sanitary Seal on Casing ~ Depression Around Wellhead ~ /'~ ¢ ' ; On Adjoining Lots /Oo / ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~"-¢ L//~'~-' Size /~'s'-'~ No. of Compartments Standpipes (~.Y.~ Air-tight Caps~N¢ Foundation Cleanout~'//N'~' Depression over Tank..(.~¢~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) /~/'~' ; for To Property Line To Water ,~McJn/Service Line Course Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well /,¢o / ~4:~ /4- Temporary Holding Tank Permit (Y/N) To Building Foundation ~"~'¢~" To Disposal Field '~--" To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ ~ ~..//~,~O ~-~ Width of Field Square Feet of Absorption Area Depression over Field,,(-Y'~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well / O° ¢ To Building Foundation ,~'(0 Lot 30 ~ ~ ~,~ Z-. %- ~ 1 ~,(-- Type of System Design Length of Field Depth of Field ¢O~ ¢ Gravel Bed Thickness Standpipes Present~.J~)' /,,/.~/~te of Last Adequacy Test To Water-MaiTCService Line /O I ;- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots ~:,~O To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) __ "~u¢~p Off Level at u les during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** S & S ENGINEERING ' certify th~ ~lavf¢~ked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this inspection. Signed ~1~ Date ,~.~,~ 2 8 !986 Company MOA No. ¢~'-~ ~'~ ~ Receipt No, __--?~ S ~'L~0 Date of Payment C.~ ~ c'~L.c~(_.(~.~ Amount: $ ~'¢~ ~¢-~ Page 2 of 2 72-026 (11/841 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF iNSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SiTE SEWER AND WATER FACILITY 264-4720 A pplicat ion Date '-~-/~'/~'.~ GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) /.r.,c m /= z- (b) Applicant Name,/~r.~'~/--'/ .~//~./' Telephone: Home Business~'~-¢,/-~- ,~-'~'~-- ApplioantAddress ! //~2'¢'0/¢ ~-~/'~ /~-~'~5 ~ '~ (c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer, r,r~; Other [] (explain); Lending Institution Address Real Estate Company and Agent Address Telephone (d) /...J'/..~ ,2~ ~ Telephone (f) ~e HAA to the following address: TYPE OF RESIDENCE Single-Family,~' Multi-Family [] Number of Bedrooms ¢ Other WATER SUPPLY Individual Wel~'~ Community [] Public [] Note: If community well system, must have written confirmation from the State Departmedt of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite/~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, Page 1 of 2 72 025 (15/8% ENGINEERING FIRM PROVIDING ~NSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm "~" ,01~,~ !g~,~C .~.-~, Telephone Address .... ,,- Date ' DHEP APPROVAL Approved tor~;-~ ~) bedrooms by Approved r'~ Disapproved Terms of Conditional Approval ~ Date Conditional CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain tederal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 I, AUN~CIPAEI]'¥ OF ^NCHORAG~E . D~-PT, OF HEAETH & [NVIP. ONMI~NTAL pROTECTION WELL DATA Static Water Level ~.~"'/' Casing Height Above Ground Wiring in Condu((~/N) Electrical Separation Distances from Well: well Classification ,,~/~'/"~'/~-~-- ifA, B, C, D.E.C. Approved (Y/N) Well Log Present ~ Date Completed~~O ~ ~ / ¢~ Yield~¢~ Total Depth 7 Cased to ~ ~ Depth of Grouting ~ Pump Set At ~ ~ Sanitary Seal on Casin~N) Depression Around Wellhea~ d (Y~ To Septic/H~ff~'~Tank on Lot ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot To N~er;~to ~r~iaCn~ee r Lin e d ¢ ~/~./¢'~' To ~; aNr ees~r ~twP; b~i;r vSi; eW ~_ri n e o r; L ct Water Sample Collected bye' Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed Standpipe (~) Depression over Tank (Y,~N~/ Pumping/Maintenance Contract on File (Y/N) / Holding Tank High-Water Alarm (Y/N) [ ~ Temporary Holding Tank Permit (Y/N) Size /',,2.,,.,~"'~ ' No. of Compartments Air-tight Cap (~) Foundation Cleanout,~*lb Date Last Pumped t.~ Separation Distances from Septic/lff°tdl?~eTank: To Water-Supply Well To Property Line To Building Foundation '-~ (.~ To Disposal Field ~? To Water Main/Service Line Course To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72 026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed __/ Width of Field Square Feet of Absorption Area Depression over Field (Y~) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well ___//~ (' To Building Foundation _ Lot .~-~0 r To Water f~ff~./Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Length of Field .~-~ Depth of Field Gravel Bed Thickness Standpipes Present¢/N) Date of Las~/&dequacy Test v /' To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) D. LIFT STATION Date Installed Size in Gallon~ "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) / _,~ / "PimPOff''Levelat / ~F J~umep~i~ (gY~:les during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against FIAA Request ** I certify that I have checked, verified, or conformed to all MOA and H~A guidelines in effect on the date of this inspection. Company Receipt No. Date of Payment Amount: $ Page 2 of 2 72-026 (11/84)